Risk-adjusted analysis of long-term outcomes after on- versus off-pump coronary artery bypass grafting (original) (raw)
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European Heart Journal, 2006
Aims To assess the benefit of off-pump coronary surgery stratified by the pre-operative risk profile. Methods and results Prospective and multicentric cohort study. All consecutive patients undergoing a first coronary bypass procedure between November 2001 and November 2003 were potentially eligible. Pre-operative EuroSCORE and in-hospital outcomes were prospectively collected using strictly standardized criteria. To ensure optimal adjustment, a propensity score was constructed using clinically relevant variables and incorporating individual centres. Of 1602 patients who underwent a first coronary bypass, EuroSCORE could be calculated in 1585: 787 were of moderate/high pre-operative risk profile (EuroSCORE. 3), of which 347 underwent off-pump procedures, and 798 were of low pre-operative risk profile (EuroSCORE 3), of which 349 underwent off-pump procedures. After risk adjusting for propensity score, off-pump patients had less major events (post-operative death, myocardial infarction, and need for reoperation). This benefit was higher in the low-risk stratum (OR ranged between 0.27 and 0.4; P ¼ 0.02 2 0.07) than in the high-risk stratum (OR between 0.4 and 0.7; P, not significant). Conclusion In real-life conditions, off-pump coronary surgery may be more effective than on-pump surgery. In contrast with previous reports, our results suggest that this benefit may be higher in patients with low pre-operative risk.
2021
Background Despite several studies comparing off- and on-pump coronary artery bypass grafting (CABG), the effectiveness and outcomes of off-pump CABG still remain uncertain. Methods In this registry-based study, we assessed 8163 patients who underwent isolated CABG between 2014 and 2016. Propensity score matching (PSM), inverse probability of weighting (IPW) and covariate adjustment were performed to correct for and minimize selection bias. Results The overall mean age of the patients was 62 years, and 25.7% were women. Patients who underwent off-pump CABG had shorter length of hospitalization ( p < 0.001), intubation time ( p = 0.003) and length of ICU admission ( p < 0.001). Off-pump CABG was associated with higher risk of 30-days mortality (OR: 1.7; 95% CI 1.09–2.65; p = 0.019) in unadjusted analysis. After covariate adjustment and matching (PSM and IPW), this difference was not statistically significant. After an average of 36.1 months follow-up, risk of MACCE and all-...
A Risk Score for Predicting Long-Term Mortality Following Off-Pump Coronary Artery Bypass Grafting
Journal of Clinical Medicine
Background: Off-pump coronary artery bypass grafting (OPCAB) comprises 15–30% of all bypass grafting surgeries. The currently available perioperative scores such as Euroscore and STS score do not specifically predict long-term mortality after off-pump procedures. The neutrophil-to-lymphocyte ratio (NLR) is one of the new, easily accessible markers of inflammation with proven predictive value in cardiovascular diseases. We aimed to develop the first risk score for long-term mortality after OPCAB and to determine if the perioperative value of NLR predicts long-term mortality in OPCAB patients. Methods: In total, 440 consecutive patients with multivessel stable coronary artery disease undergoing OPCAB were recruited. Differential leukocyte counts were obtained by a routine hematology analyzer. Data regarding mortality during a median follow-up time of 5.3 years were obtained from the Polish National Health Service database. An independent population of 242 patients served as a validati...
Journal of the American College of Cardiology, 2018
on-pump versus off-pump CABG needs to be recalculated. In the present study, the HRs (from log-rank test or Cox regression model) of on-pump versus offpump CABG were extracted from the 6 articles that were recruited by Smart et al. (1). Two studies did not provide the HR (3,4). According to the observed events in the on-pump and off-pump CABG groups and the p value for log-rank test, we calculated the HR and corresponding 95% confidence interval (CI). Altogether, the pooled HR for this comparison (on-pump vs. off-pump CABG) was 1.08 (95% CI: 0.95 to 1.23; p ¼ 0.24, p Heterogeneity ¼ 0.25) (Figure 1). The result indicates that long-term prognosis using on-pump CABG had no significant difference compared with those using off-pump CABG.
Outcomes for Off-Pump Coronary Artery Bypass Grafting in High-Risk Groups: A Historical Perspective
The Heart Surgery Forum, 2005
Background: The outcomes of off-pump coronary artery bypass (OPCAB) and conventional coronary artery bypass grafting with cardiopulmonary bypass (cCABG) have been compared in detail. Similarly, several reports have examined outcomes of high-risk subsets of patients in OPCAB as a selection strategy for reducing morbidity and mortality compared to cCABG. We undertook a retrospective study comparing outcomes from the early years in our experience of beating-heart surgery in high-risk patients selected for OPCAB compared to low-risk patients having OPCAB. This study was premised on strict selection criteria in an era prior to stabilizing devices and cardiac positioners. Methods: A total of 384 patients underwent OPCAB over a 10-year period. Clinical outcomes were compared for 280 low-risk patients and 104 high-risk patients (redo CABG, CABG with simultaneous carotid endarterectomy, or renal insufficiency/failure). Results: The high-risk group patients were significantly older than the l...
Off-Pump Coronary Artery Bypass Disproportionately Benefits High-Risk Patients. Discussion
The Annals of Thoracic Surgery, 2009
Background. It is not known which patient subgroups may benefit most from off-pump coronary artery bypass grafting (OPCAB) rather than coronary artery bypass grafting on cardiopulmonary bypass (CPB). Methods. The Society of Thoracic Surgeons database was queried for all isolated, primary coronary artery bypass graft cases between January 1, 1997, and December 31, 2007, at a US academic center. The Society of Thoracic Surgeons Predicted Risk of Mortality (PROM) was calculated by a formula based on 30 preoperative risk factors. It was used in three ways to compare 30-day operative mortality between patients treated with OP-CAB versus CPB. First, patients were divided into quartiles based on their PROM, and mortality rates were compared between OPCAB and CPB patients within each PROM quartile. Second, a logistic regression model tested for an interaction between surgery type and PROM; a significant interaction would indicate that the relative mortality risk of OPCAB versus CPB varied with different PROM levels. Finally, locally smoothed kernel regression curves were used to visually estimate a threshold PROM point at which mortality rates diverge for the surgery types. Results. There were 14,766 consecutive patients, 7,083 OPCAB (48.0%) and 7,683 CPB (52.0%). There was no difference in operative mortality between OPCAB and CPB for patients in the lower two risk quartiles. In the higher risk quartiles there was a mortality benefit for OPCAB (odds ratio, 0.62 and 0.45 for OPCAB in the third and fourth risk quartiles). Logistic regression analysis confirmed a significant interaction between surgery type and PROM (p ؍ 0.005) meaning that OPCAB is especially beneficial to patients with higher PROM. This benefit is most significant for patients with PROM values above 2.5% to 3%, where mortality curves sharply diverge. Conclusions. Off-pump coronary artery bypass grafting is associated with lower operative mortality than coronary artery bypass grafting on CPB for higher risk patients. This mortality benefit increases with increasing PROM.
Health Technology Assessment, 2014
Background: Coronary artery bypass grafting (CABG) is the treatment of choice for patients with multivessel coronary artery disease (CAD). Evidence from randomised controlled trials (RCTs) in low-risk populations shows that 'off-pump' CABG is at least as safe as 'on-pump' CABG, but high-quality trial data in high-risk populations are lacking. Objectives: To test the hypothesis that, in high-risk patients, off-pump coronary artery bypass grafting (OPCABG) reduces mortality and morbidity without causing a higher risk of reintervention compared with on-pump coronary artery bypass grafting (ONCABG). Design: Open parallel-group RCT with a 1 : 1 allocation ratio and expertise-based randomisation. Setting: Eight specialist cardiac surgery centres in the UK and one specialist centre in Kolkata, India. Participants: Patients with an additive European system for cardiac operative risk evaluation score (EuroSCORE) of ≥ 5, undergoing non-emergency isolated CABG via a median sternotomy. Interventions: CABG without cardiopulmonary bypass (CPB), i.e. OPCABG on the beating heart, or CABG with CPB, i.e. ONCABG on a chemically arrested heart. Main outcome measures: Primary outcomea composite of death or serious morbidity [all-cause mortality, myocardial infarction (MI), stroke, prolonged initial ventilation, sternal wound dehiscence] within 30 days of surgery. Secondary outcomesquality of life (QoL) [Rose Angina Questionnaire, Canadian Cardiovascular Society (CCS) angina class, European QoL-5 Dimensions (EQ-5D), Coronary Revascularisation Outcome Questionnaire (CROQ)] and resource utilisation. Results: The organisation of a tertiary cardiac surgery service in the UK presented several barriers to recruitment. Referral information was often inadequate to confirm eligibility. Limited surgeon participation at a centre, the need to meet referral-to-treatment performance targets and complex referral pathways did not support an expertise-based allocation. Urgent patients waiting for surgery in local 'feeder' hospitals were often not transferred until late the night before surgery, which limited the time available to take † See Appendix 1 for a list of investigators
European Journal of …, 2008
Background: The purpose of this study was to compare early and late results of redo-CABG with (redo-ONCAB) and without (redo-OPCAB) cardiopulmonary bypass. Methods: From April 2001 to September 2006 redo-CABG was performed in 110 patients (redo-ONCAB = 50 and redo-OPCAB = 60). Applying the propensity score, 43 OPCAB patients were matched with 43 ONCAB patients. The mean EuroScore was 5 AE 4.7 and 5 AE 3.4 for redo-ONCAB and redo-OPCAB, respectively ( p = 0.5). The number of diseased coronary arteries was 3 AE 0.5 and 2 AE 0.8 in redo-ONCAB and redo-OPCAB, respectively ( p < 0.01). Results: Twelve patients underwent OPCAB through anterior thoracotomy while the rest of the patients (n = 74) underwent median sternotomy. Mean number of grafts performed was 3 AE 0.8 in redo-ONCAB and 2 AE 0.6 in redo-OPCAB ( p < 0.05). The need for postoperative insertion of intra-aortic balloon pump (IABP) was higher ( p = 0.02) in redo-ONCAB (n = 9, 21%) than redo-OPCAB (n = 1, 2%). The duration of postoperative ventilation was 55 AE 98.7 h for redo-ONCAB and 10 AE 12.8 h for redo-OPCAB ( p = 0.008). No differences were found in the incidence of other postoperative complications. The 30-day mortality rate was 6.9% for redo-ONCAB (n = 3) and 2.3% redo-OPCAB (n = 1; p = NS). Mean follow-up for redo-ONCAB was 30 AE 21.3 months (range 0.1-63 months) and that of redo-OPCAB was 37 AE 19.2 months (0.1-62.5 months). Actuarial survival at 5 years was 87 AE 5.5% for redo-ONCAB and 95 AE 3.2% for redo-OPCAB ( p = 0.17). Event-free survival was 71 AE 8.0% for redo-ONCAB and 78 AE 7.2% for redo-OPCAB ( p = 0.32). Conclusion: OPCAB is an acceptable strategy in selected patients requiring redo-CABG. Employing a strategy of OPCAB for those patients with 2 or fewer lesions and ONCAB for those with more diffuse disease, redo-OPCAB and redo-ONCAB have similar early and late outcomes. #